England’s NHS most efficient of devolved countries

The NHS in England has outperformed its peers in the rest of the UK on a number of criteria and is offering better value for money, claims an eye-opening report by research charity The Nuffield Trust.

The charity looked at certain key performance measures for national health services in England, Scotland, Wales and Northern Ireland at three different time points – 1996/7, 2002/3 and 2006/7 - in order to examine, for the first time, the impact of different systems, policies and priorities in health across the countries following devolution in 1999.

Its research revealed that, while the NHS in England spends less cash and employs fewer medical staff per capita than any of the other devolved countries, it seems to making better use of resources “in terms of delivering higher levels of activity, crude productivity of its staff and lower waiting times”.

On the flip side, Scotland performed worst on nearly all of the criteria examined, spending the most cash and having more doctors and nurses per head of population than its counterparts, but, at the same time, showing the highest levels of poor health and the lowest rates of crude productivity and inpatient admissions per capita in 2006/7.

Similarly, national health services in Wales and Northern Ireland also failed to offer the same level of value for money during the time period studied, with both nations spending more money but achieving less crude productivity than England, the report found.

Furthermore, in terms of waiting lists, both Wales and Northern Ireland (comparisons could not be drawn with Scotland on this criteria because of differences in data handling) performed far worse than England. For example, by 2006, almost all patients in England had an outpatient appointment within three months, while 44% of patients in Wales and 61% in Northern Ireland had to wait longer, highlighting stark differences on this measure too.

Moreover, according to the report, the differences observed in both waiting times and staff productivity were even more pronounced when the devolved nations were pitted against those English regions that were most similar to them on a set of health and socio-economic indicators, making for a more even comparison.

Jennifer Dixon, Director of The Nuffield Trust, said the report’s findings raise “challenging” questions about the efficiency of care across the devolved nations.

Different policiesWhile some of the marked differences in measures such as productivity can be blamed on historical differences in funding levels, she said, “some will reflect the different policies pursued by each of the four nations since 1999, in particular the greater pressure put on NHS bodies in England to improve performance in a few key areas such as waiting and efficiency, via targets, strong performance management, public reporting of performance by regulators, and financial incentives”.

According to Nigel Edwards, director of policy at the NHS Confederation, the report “demonstrates that different parts of the UK have different priorities, which produce different results,” but he stressed: “It does not tell us who has the best health system.”

“Each of the four countries have their strengths and weaknesses, and only the collection of better and more comparable UK-wide data would allow us to make a judgement about who was performing best overall,” he explained.

A spokesperson for the Scottish government was also critical of the comparisons being drawn by the report, for one stressing to PharmaTimes UK News that its findings are “based on data that's at least three years old and is out of date”.

Since then, the spokesperson claimed there have been “significant improvements” in NHS Scotland's performance, such as a massive reduction in the number of people waiting more than 12 weeks for a new outpatient appointment, from around 12,500 in March 2008 to 190 in September 2009.

Furthermore, measures of productivity in particular “fail to take into account the complexity or severity of cases before treatment - nor the quality of outcomes,” she argued, and added that the measures also “only cover a narrow range of hospital procedures and do not reflect the shift in the balance of care from the acute sector into the community in Scotland”.

Instead, she stressed that “every penny spent in the NHS secures good outcomes for patients and good value for money” and that, “even with a significantly more peripheral and sparse population than the rest of the UK – which affects the numbers of medical staff and facilities needed - the latest information shows £1,986 was spent per person in Scotland in 2008-9, less than in London and marginally less than the North-East of England”.

Nevertheless, the Department of Health in England has welcomed the report and said it plans to “study the findings carefully”. As a DH spokesperson explained to PharmaTimes: “Devolution allows each country to have the freedom to make decisions about the health needs of their population and to focus on disease prevention, health promotion and health services in a way that is best for their public”.

Shortest waits since records beganPatients in England can now expect the “shortest waits since records began”, and to build on this performance patients have now been handed legal rights maximum waiting times under the NHS Constitution, the spokesperson added.

But, Katherine Murphy, Director of the Patients Association, has attacked the disparity across the UK’s health services. “In each country of the UK patients feel they are not getting the NHS that others are getting” she said, adding: “This year of all years the question to be answered is ‘Do we have a National Health Service any more or not?’”.

All arguments aside, Dixon highlighted “a lack of comparable data that allow differences in performance across the UK to be analysed in depth in future”, and added that “without such comparable data, UK taxpayers and HM Treasury cannot know whether they are securing value for money for their health services”.

On a different note, Edwards also stressed that the existence of four health systems under one roof is “a recent phenomenon and it will take considerable time, and more data, before it is possible to draw robust conclusions about what works best in each of the UK’s constituent nations”.